Abstract Details

Title Syndrome of Transient Headache and Neurological Deficits with Cerebrospinal Fluid Lymphocytosis (HaNDL): A Case Report with Newly Described Electroencephalography (EEG) findings, Symptomatic Treatment Strategies, and Literature Review

Topic Headache

Presentation(s) P5 - Poster Session 5 (5:30 PM-6:30 PM)

Poster/Presentation
Number 13-008

Objective To describe a case of HaNDL that presented with generalized disorganized pattern on EEG.

Background Initially described in 1981, HaNDL remains under recognized. Diagnosis is made via clinical history and cerebrospinal fluid analysis. However, the invasiveness of lumbar puncture (LP) has limited establishing the diagnosis. Case series utilizing EEG have shown focal slowing including frontal intermittent rhythmic delta activity, but to our knowledge generalized disorganization has not been described.

Design/Methods PubMed was searched using keyword “headache and neurologic deficits with cerebrospinal fluid lymphocytosis”, “migraine with cerebrospinal pleocytosis”, and “pseudomigraine with lymphocytic pleocytosis”

Results 37-year-old immunocompetent male presented with headache and focal neurological symptoms. One week earlier at an outside hospital patient had similar symptoms and was diagnosed with migraine. His symptomology includes progressing right sided numbness starting in lower extremity followed by extension to contralateral side, migrainous headache, and concurrent aphasia. MRI of brain displayed scattered subcortical white matter demyelination without restricted diffusion. Continuous video-EEG while symptomatic demonstrated markedly disorganized background compromising by a mixture of theta, delta, alpha and beta with poorly developed/sustained posterior dominant rhythm (PDR). LP was non-traumatic (RBC 19) with elevated opening pressure (36 cmHg), lymphocytic pleocytosis (WBC 12, 97% lymphocytes), elevated protein (153 mg/dl) and normal glucose (60). Extensive infectious testing was negative. Background EEG displayed improvement with organization and normalization of PDR following treatment with valproic acid and tizandine.

Conclusions HaNDL remains an under recognized entity partially due to the invasive testing required to establish diagnosis. A firm diagnosis is essential as patient’s have high likelihood of recurrent attacks, which increase healthcare utilization. Our case highlights the natural history of a newly described EEG, which may represent a new clinical sign to help raise suspicion for HaNDL as well as provide support for the invasive testing required to establish the diagnosis.

Authors/Disclosures
Sam Hooshmand, DO (Medical College of Wisconsin) PRESENTER	Dr. Hooshmand has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Genetech USA. Dr. Hooshmand has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for TG Therapeutics . Dr. Hooshmand has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Amgen. Dr. Hooshmand has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genetech USA. Dr. Hooshmand has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for EMD Serono. Dr. Hooshmand has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for TG Therapeutics . Dr. Hooshmand has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Amgen . The institution of Dr. Hooshmand has received research support from Novartis .
	No disclosure on file
Fallon Schloemer, DO (Medical College of Wisconsin Affiliated Hospitals)	Dr. Schloemer has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Lilly . Dr. Schloemer has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Abbvie .

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